Provider Demographics
NPI:1942233895
Name:ANGELA G BOWERS, MD PA
Entity Type:Organization
Organization Name:ANGELA G BOWERS, MD PA
Other - Org Name:SOUTHLAKE DERMATOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:817-251-6500
Mailing Address - Street 1:1170 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-251-6500
Mailing Address - Fax:817-442-0550
Practice Address - Street 1:1170 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-251-6500
Practice Address - Fax:817-442-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG38715Medicare UPIN
TX00748RMedicare ID - Type Unspecified